Hernias Flashcards
What is a hernia?
Protrusion of a viscus either in part or in whole from its enclosed cavity, through a potential space or anatomical weak point
All hernias are made up of
The mouth
The neck
The body
The fundus
Except?
Incisional hernia
Epigastric hernia
Hernia could also be classified according to its accesibility into
INTERNAL HERNIAS
1. Tentorial hernias (in the brain)
2. Diaphragmatic hernias
3. Stammer’s (Patterson’s) hernia – Mesenteric hernia
4. Paraduodenal Hernias
EXTERNAL HERNIAS
VENTRAL HERNIAS
1.Groin hernias
Femoral hernia
Inguinal Hernias
2. Umbilical Hernias
Supra-umbilical hernia
Infra-umbilical hernia
3. Incissional hernias (via previous scars)
3. Epigastric Hernia
LATERAL HERNIAS (LOSS)
1. Lumbar Hernias
2. Obturator Hernias
3. Sciatic hernias
4. Spigelian hernias
Briefly discuss the aetiology of hernias
A. WEAKENED ABDOMINAL WALL
Congenital
1. Patent processus vaginalis
2. Omphalocoeles
3. Weakened internal ring seen in Marfan’s syndrome, Prune-belly syndrome
4. Sites of vascular penetration causing pre-peritoneal hernia
Acquired
1. Infection e.g omphalitis, wound infection
2. Obesity
3. Ageing
4. Injury to motor nerves
B. INCREASED INTRA ABDOMINAL PRESSURE
1. Chronic Cough eg COPD
2. Bladder outlet obstruction eg stricture, BPH
3. Heavy manual work
4. Pregnancy – Frequent/multiple pregnancies
4. Ascites/Abdominal tumours etc
Discuss the natural history of hernias
1) Hernias starts as Reducible hernia
2) Then becomes Irreducible:- This is due to incarceration.
3) Obstructed Hernia:- No venous return but arterial flow. Mass becomes bigger, painful, irreducible but viable.
4) Strangulated hernia:- Both venous and arterial supplies are cut-off. Contents become ischemic, putrfy and gangrene sets in.
5) Perforated hernia:- If strangulated hernia is left untreated, it can perforated to the exterior (enterocutaneous fistula) or to the interior (peritonitis)
Inguinal hernias are the most commonly strangulated hernias.
True or False?
False
Femoral hernias strangulate more often than inguinal hernias
Indirect hernias strangulate more commonly that direct hernias.
True or False
True
Small bowl strangulation is commoner on the right side than on the left side
True or false
True
List the possible causes of incarceration in hernias
1) impacted faces
2) adhesions
3) bulky distended loops of bowel
4) sliding hernias
For indirect inguinal hernias, where does the herniating part enter the inguinal canal from?
Internal ring (deep inguinal ring)
For indirect inguinal hernias, where does the herniating part exit the inguinal canal from?
Superficial ring (superficial inguinal ring)
What is the commonest type of hernia in both males and females?
Inguinal hernia
For males Indirect hernias are more common on the right than on the left
True or False
True
Because if the late descent of the right testis
What are the boundaries of the inguinal canal
2(MALT)
Roof:- 2 Muscles
i. Internal oblique
ii. Transversus abdominis
iii. Transversalis fascia
Anterior wall:- 2 Aponeurosis
i. Aponeurosis of external oblique
ii. Aponeurosis of internal oblique
Floor:- 2 Ligaments
i. Inguinal ligament
ii. Lacunar ligament
Posterior wall:- 2
i. Transversalis fascia
ii. Conjoint Tendon
For direct hernias, herniating contents enter the inguinal canal through?
Posterior wall of the inguinal canal (Transversalis fascia) through the Triangle of Hasselbach
Direct hernias are more common on the left than on the right
True or False
False
They have equal distribution
What lies anterior to a direct hernia
Spermatic cord
In indirect hernias, the sac lies (antero-)medial to the cord.
In direct hernias, the sac lies behind the cord with the inferior epigastric artery lying lateral to the neck.
What lies superior to a direct hernia
Epigastric artery
Where is the opening of the inguinal canal located and what is its clinical importance?
Location:- Midpoint of the inguinal ligament. This is the midpoint from the ASIS to the pubic tubercle
Clinical importance:- On examination, if you perform a ring occlusion (plugging the internal ring with your finger) and there is still herniation on coughing = Direct hernia until proven otherwise.
What is the mid-inguinal point and what is the clinical importance
This is the midpoint between the ASIS and the pubic symphysis.
Clinical importance:- This is where the femoral pulse is checked.
Direct inguinal hernias are common in females
True or False
False
They are rare
What is a *PANTALOON HERNIA**
An inguinal hernia in which part of the sac is indirect (lateral to inferior epigastric) while another comes direct (medial to inferior epigastric) through the triangle of Hasselbach.
Having the inferior epigastric artery in-between the two is called
What is an incomplete hernia
Groin Hernias that remain above the groin crease
What is a Complete hernia.
Hernia exits the external ring and enters the scrotum (or labium majus). inguino-scrotal or inguino-labial
What is a bubonocoele
An incomplete hernia that is limited to the inguinal canal
What is a funinculocoele
A hernia has traversed the external ring and lies just above the pubic tubercle – on the spermatic cord
What is a pro-peritoneal hernia
It is an indirect hernia, on emerging through the internal (deep) ring, turns upwards to lie between transversalis fascia and peritoneum
Lies between a fascia and peritoneum
What is an interstitial hernia
It is an indirect hernia, on emerging through the internal (deep) ring, turns upwards to lie between transversalis fascia and transverse abdominis muscle
Lies between a fascia and muscle
What is an interparietal hernia
It is an indirect hernia, on emerging through the internal (deep) ring, turns upwards to lie between
internal oblique or transversus abdominis or even external oblique
Lies between 2 muscles
To avoid recurrence of a hernia, what do you do during repair?
Tightening the ring by Lyttle’s stitch or Plug and patch technique
What are the boundaries of the hasselbach’s triangle
•Medially by the lateral border of the rectus sheath,
•Laterally by the inferior epigastric artery
•Inferiorly (base) by the Inguinal ligament.
How do you examine a hernia
1) Confirm the presence of the hernia:- palpable cough; Vissible cough impulse.
2) Determine whether it inguinal or femoral hernia:- The neck of an inguinal hernia is above the inguinal ligament.
3) Determine whether it is a direct or indirect hernia:- Perform a ring occlusion (block). Most complete inguinal hernias are indirect.
List the differential diagnosis for a hernia
- Femoral Hernia
- Hydrocoeles
- Malgaignes’ bulges
- Undescended and ectopic testes
- Lymphadenopathy
- Saphena varix, femoral artery aneurysm
- Lipoma
- Psoas Abscess
What are the treatment options for a hernia
● Herniotomy
● Lyttle’s procedure
● Repair of Defect:
(i)Herniorhapphy
(ii)Hernioplasty
(iii)Laparoscopic
What are the Indications for Laparoscopic Repair
●Recurrent hernia
●Bilateral hernia
●Need for speedy return to work
What are the contraindications for laparoscopic repair?
• Huge inguino – Scrotal hernia
• Irreducible hernias
• Lower midline incissions
• Previous pre-peritoneal surgery like prostatectomy
What are the Post-operative complications of Hernia repair
Early
Pain
Urinary retension
Scrotal Haematoma
Vasectomy
Late
Wound infections
Testicular infarction
Transient testicular orchitis
Post-operative Hydrocoele
Impotence
Recurrence
What are the Causes of hernia Recurrence
●Size and duration of the hernia
●Age of the patient. Recurrence is higher over 48yrs
●Sliding hernias recur more
●Over-looked Pantaloon hernia
●Technical details – like suture material. Tension repairs recur earlier.
●Persistent increase in abdominal pressure
●Wound infection
●Sex. Recurrence is less in women
Femoral hernia affects men more than women.
True or false?
False
Femoral hernia affects women more than men
Where is the entry point for femoral hernia
Femoral ring
List the The boundaries of the Femoral canal
●Anteriorly – Inguinal ligament
●Posteriorly – Pectineal fascia (Cooper’s ligament)
●Medially – lacunar ligament
●Laterally – Femoral Vein.
The sax in femoral hernia exits from the femoral canal via the?
Fossa ovalis
Differential diagnosis for femoral hernia
Inguinal hernia
Femoral vein aneurysm
Lymph node enlargement
Lipoma
Treatment modality for femoral hernia
●Low operation of Lockwood
●High operations:
(i) Lotheisein inguinal approach
(ii) extra peritoneal approach
What are the complications of hernia reduction?
●Reduction-en-mass. This is return of unreduced hernia contents together with the sac into the peritoneal cavity. If this was done by patient it is called “auto reduction-en-masse”.
● Reduction of de-vitalised tissue into the peritoneal cavity.
● Bowel may develop stricture at point of strangulation
Is resuscitation needed before surgery for hernia repair?
Yes
Resuscitate before Surgery
•N/G tube, Urinary catheter, Antibiotics,
•Adequate fluid input/output
•Adequate analgesia
•Monitor vital signs: BP, Pulse, RBS, Sp02
•Blood tests and transfusion
